Provider Demographics
NPI:1417037532
Name:JEFFERSON COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:JEFFERSON COUNTY BOARD OF HEALTH
Other - Org Name:JEFFERSON COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REIDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-728-8416
Mailing Address - Street 1:1948 WILTSHIRE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KEARNEYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25430-2783
Mailing Address - Country:US
Mailing Address - Phone:304-728-8416
Mailing Address - Fax:304-728-3319
Practice Address - Street 1:1948 WILTSHIRE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430-2783
Practice Address - Country:US
Practice Address - Phone:304-728-8416
Practice Address - Fax:304-728-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA72206251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0019461000Medicaid
WV0019461001Medicaid
WV0019461001Medicaid